Pain Free as Possible - Medication Management - Managing Risk

Pain Free as Possible

People should die in a way that is as free from pain as possible.

  • Failure to identify that the person is in pain including where they may be experiencing breakthrough pain.
  • Failure to monitor and respond to non-verbal pain cues.
  • Appropriate pain medication not being given because staff fear that these medications are addictive, will hasten death, or have legal ramifications.
  • Educate and empower staff about identifying pain cues and effective pain management in the palliative care context.
  • Foster dialogue across the multi-disciplinary care team.
  • Reassure staff that providing effective pain relief is expected,necessary, and good clinical practice, and that appropriate provision of pain and symptom relief intended to relieve pain and suffering is lawful.
  • Create procedures that clearly outline pain management protocols with specific trigger points that prompt staff to carry out reassessment as needs change or consider the use of breakthrough pain relief as needs change.
  • Ensure medicines to manage pain and symptoms are prescribed, administered and available 24-hours a day.
  • Undertake reflective practice to self-assess attitudes toward death, dying and symptom relief.
  • Monitor staff practice to ensure they can detect non-verbal pain cues.
  • Use medication reviews to seek insights into prescribing behaviours and administration practices.
  • Seek feedback from the person, or, with the person’s consent, their family, friends and support networks. If the person lacks capacity, seek feedback from their substitute decision-maker.
  • Ensure the individual and/or substitute decision-maker has an appropriate communication aid or tool to describe pain and intensity to the staff member. 

Effective pain management is critical

Effectively relieving pain is one of the primary goals in the palliative phase. Reducing unnecessary suffering and avoiding painful death is a priority. Medicines to manage pain and symptoms need to be prescribed, administered and available 24-hours a day. 

The following diagram depicts barriers to administering effective pain relief identified in a 2022 Australian study of nurses working in different end of life (EOL) settings, including residential aged care.18

Fears regarding symptom relief - hastening death, addiction, loss of consciousness, legal or professional repercussions. Lack of knowledge, experience and training - medication and palliative care, symptom assessment, recognising the end of life, relevant law. Personal, cultural and religious beliefs - staff's beliefs, patients and families beliefs. Lack of communication - within treatment teams, between staff, patient and families. Institutional barriers - time constraints, lack of institutional support, access issues.

Health professionals and staff need to be alert to whether the person is experiencing pain including breakthrough pain – which the person may experience between regularly scheduled doses of medication.  It is important that care staff are alert to the way that the individual person communicates pain, including how to recognise non-verbal pain cues. This includes, for example, being alert to signs of grimacing, moaning, jaw-tightening, flinching and clenching of fists or blankets.

Being responsive to the person’s pain also relies on staff having good knowledge and an authorising environment that supports effective pain management in the palliative care context. Openly discussing concerns that staff may have around administering pain relief to dispel any myths or preconceptions is important. Clear support from leaders will help staff feel secure in administering pain relief.

Reluctance to give high doses of pain relief – particularly opioids - out of concern the person might become addicted should be set aside in the palliative phase, provided these higher dosages are needed to manage their pain.

There may also be reluctance to administer pain and symptom relief due to concerns it may hasten the person’s death and have legal consequences. Providing pain and symptom relief is lawful in Australia if the intention of the person giving the medication is to relieve the person’s pain and symptoms and not to cause or hasten death.

Aged care providers and staff should be aware of these barriers and work with people, their family and friends to find strategies to overcome and manage them as they arise.

  • Resources

ELDAC End of Life Law Toolkit 

Page updated 06 February 2024